Nonsteroidal anti-inflammatory drugs for dysmenorrhoea

Marjoribanks J, Proctor M, Farquhar C, Derks RS

Published Online:

January 20, 2010

Nearly three quarters of women suffer from period pain or menstrual cramps (dysmenorrhoea). Dysmenorrhoea is thought to be caused by the uterus producing too much prostaglandin (a hormone). Nonsteroidal anti-inflammatory drugs (NSAIDs) restrict the production of prostaglandins. NSAIDs include the common painkillers aspirin, naproxen, ibuprofen and mefenamic acid. The review found that NSAIDs are effective in relieving period pain and appear to work better than paracetamol, but it was unclear whether any one NSAID is safer or more effective than others. NSAIDs can cause adverse effects, including indigestion, headaches and drowsiness.

Abstract (click to read)

Background:

Dysmenorrhoea is a common gynaecological problem consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs which act by blocking prostaglandin production.

Objectives:

The purpose of this review is to compare nonsteroidal anti-inflammatory drugs used in the treatment of primary dysmenorrhoea versus placebo, versus paracetamol and versus each other, to evaluate their effectiveness and safety.

Search strategy:

We searched the following databases to May 2009: Cochrane Menstrual Disorders and Subfertility Group trials register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and Web of Science. The National Research Register and the Clinical Trials Register were also searched. Abstracts of major scientific meetings and the reference lists of relevant articles were checked.

Selection criteria:

All randomised controlled comparisons of NSAIDs versus placebo, other NSAIDs or paracetamol, when used to treat primary dysmenorrhoea.

Data collection and analysis:

Two reviewers independently assessed trials for quality and extracted data, calculating odds ratios (ORs) for dichotomous outcomes and mean differences for continuous outcomes, with 95% confidence intervals (CIs). Inverse variance methods were used to combine data.

Main results:

Seventy-three randomised controlled trials were included. Among women with primary dysmenorrhoea, NSAIDs were significantly more effective for pain relief than placebo (OR 4.50, 95% CI: 3.85, 5.27). There was substantial heterogeneity for this finding (I2 statistic =53%): exclusion of two outlying studies with no or negligible placebo effect reduced heterogeneity, resulting in an odds ratio of 4.14 (95% CI: 3.52, 4.86, I2=40%). NSAIDs were also significantly more effective for pain relief than paracetamol (OR 1.90, 95% CI:1.05 to 3.44). However, NSAIDS were associated with significantly more overall adverse effects than placebo (OR 1.37, 95% CI: 1.12 to 1.66). When NSAIDs were compared with each other there was little evidence of the superiority of any individual NSAID for either pain-relief or safety. However the available evidence had little power to detect such differences, as most individual comparisons were based on very few small trials.

Authors' conclusions:

NSAIDs are an effective treatment for dysmenorrhoea, though women using them need to be aware of the significant risk of adverse effects. There is insufficient evidence to determine which (if any) individual NSAID is the safest and most effective for the treatment of dysmenorrhoea.

This record should be cited as:

Marjoribanks J, Proctor M, Farquhar C, Derks RS. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001751. DOI: 10.1002/14651858.CD001751.pub2

Assessed as up to date:

August 13, 2009

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Primary Review Group:

Menstrual Disorders and Subfertility Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of primary dysmenorrhoea?

Bottom line:

Compared with placebo, NSAIDs are a highly effective treatment for dysmenorrhoea, though women using them need to be aware of the significant overall risk that they may cause adverse effects, such as indigestion, headaches or drowsiness. There is insufficient evidence to indicate whether any individual NSAID is more effective or safer than others. It appears NSAIDs are more effective than paracetamol, though there were only 3 relevant studies. Nineteen different types of cox-1 NSAIDs were evaluated in the included studies.

Caveat:

The included studies used a wide variety of continuous pain scales as their primary or sole measure of effectiveness. The measurement and reporting of adverse effects was generally poor. At least half the studies were co-authored or financially supported by pharmaceutical company associates and it was unclear how most of the other studies were funded.

Context:

Dysmenorrhoea is a common gynaecological problem, consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. NSAIDs are drugs which act by blocking prostaglandin production.

Cochrane Systematic Review:

Marjoribanks J et al. Non-steroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Reviews 2010, Issue 1. Article No. CD001751. DOI: 10.1002/14651858.CD001751.pub2. This review contains 73 studies involving 5156 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Gynaecology > Pelvic pain > Dysmenorrhea

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Nonsteroidal anti-inflammatory drugs for dysmenorrhoea

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